PFD report

Annette Lewis · Prevention of Future Deaths report

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Issued 6 Mar 2025•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to implement a “Failed Discharge” policy
    Part of recurring concern: Unreliable hospital discharge processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Implement operational general surgery guidelines for patients returning to emergency departments after discharge, and embed them in governance, staff induction and accessible policy resources.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 7 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing guidelines, policies and awareness measures are considered sufficient to prevent further similar patient presentations.

    Stated by Cwm Taf Morgannwg University Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to implement a “Failed Discharge” policy

Wider context from the report

“Annette should have been referred for surgical review rather than being discharged. Work on a “Failed Discharge” policy has been ongoing for some time. When implemented, patients re-attending Emergency Departments in similar circumstances would be automatically and swiftly filtered to the appropriate specialist team, which would reduce the risks for those individual patients and reduce the pressures and the consequent risk of errors within Emergency Departments. Progress with this policy has been difficult and there is no definitive timescale for implementation. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement operational general surgery guidelines for patients returning to emergency departments after discharge, and embed them in governance, staff induction and accessible policy resources.

Verbatim wording from the response

“1. General Surgery Policy CTM now has active and up to date guidelines to prevent recurrence of what happened in Mrs Lewis’ case. This is a General Surgery policy that applies to the General Surgeons as well as to the Emergency Department (who have also had it discussed and shared”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 1 · response
Published 7 March 2025

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing guidelines, policies and awareness measures are considered sufficient to prevent further similar patient presentations.

Verbatim wording from the response

“widely – please see below in Emergency Department section). The Guidelines for care and treatment for patients who return to an Emergency Department (ED) within CTM UHB with general surgical conditions following discharge from hospital within CTM UHB were approved at Quality & Safety Committee on the 25th March 2025. These guidelines are operational across the Health Board. It was discussed at the Surgical Governance Meeting (pan-health board) on 13th March 2025 department Morbidity and Mortality meeting, and the new policy was shared with the entire team by email. Those involved have reflected and evidenced this as part of their appraisal. Finally, this policy has been included in our induction presentation to all new starters. It is available on the Health Board SharePoint where all Guidelines and Policies are located for rapid access by colleagues.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 7 March 2025

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Disseminate Emergency Department guidelines across clinical teams and CTM emergency departments, display key information, and incorporate the policy into the departmental handbook.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 7 March 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate Emergency Department guidelines across clinical teams and CTM emergency departments, display key information, and incorporate the policy into the departmental handbook.

Verbatim wording from the response

“2. Emergency Department Policy The Princess of Wales Emergency Department Guidelines have been circulated to all Doctors and Clinical Teams. In addition, information (including laminates clearly displayed on the department walls) is available in minors, paediatric triage and BRATZ (majors triage / rapid assessment) for the whole multi-disciplinary team to see, be aware of and act upon. This is also the case in key areas in the other CTM Emergency Departments Royal Glamorgan and Prince Charles. There is a Princess of Wales Emergency Department Handbook and this policy has been added to it. This Handbook is available for all staff to refer to including agency and locum doctors.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 7 March 2025

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026